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Among Doctors, an Epidemic of Distress

While much has been written about the role that long work hours play in medical mistakes, less is known about the toll of burnout, depression and stress.

As Dr. Pauline Chen reports in today’s Doctor and Patient column, fatigue is not the only challenge that doctors in training face when trying to do their jobs well. Dr. Chen tells the story of a colleague whose work began to suffer after his wife had a baby.

In spite of the long hours and the all-consuming nature of our work, we generally managed to do our jobs and do them well. But whenever one of us experienced additional stress apart from our work, the house of cards in which we functioned would start to collapse. Unable to admit to or find support for our distress, we would continue to soldier on at the hospital, leaving a series of mistakes, ranging from barely perceptible to blatant, in our wake.

when I finished my training after three years in NYC hospitals I was unable to consider working for much of the next year–I found myself angry at sick babies, an unacceptable state. I know hours are better now, but there must be a better way of learning to be a capable caring physician. I would add that a significant part of the stress was in trying to help patients who needed more than acute medical care–they needed housing and jobs and adequate insurance. An antibiotic was little comfort.

Another great Pauline Chen column every resident should read. Doctors-in-training are allowed very little reserve. We’re trained and required to give everything we have while we’re in the hospital. As a result, when we are outside of the hospital even the slightest stressors can leave us depleted and spill over into our day-to-day performance.

Yes there has been a shift in self expectations; that physicians can be caring and patient focused, yet have a life outside of medicine. Good luck. Just as the feminist movement of the 1960’s told young women they coulld be wives, career women, and raise children effectively, resulted in a plethora of women becoming depressed that they didn’t fulfill their own expectations. So too today, young doctors and doctors-to-be, have expectations of themselves that they can “do it all”. And of course, they can’t. Anxiety and depression are the expected outcome of failure, especially when it pertains to ourselves. The other reality, people are not all alike in how we respond to distress, although in reality, very few of us handle distress with positive attitudes and behaviors. Screening for mental health issues before Medical School, during Medical School, Residency, and after completing Residency may help identify the TIME when distress is impairing our medical activities, not if. Identifying coping styles for the above groups as well as having a system (read: personnel and policies) for connecting students and residents with appropriate helping resources would go a long way to help people modify self expectations and deal with issues when they arise. Just as the military had to shut down a military base for several days to address rising incidents of suicide and put in place a mandatory plan, so too, medicine should address the distress of being committed yet distracted.

Caregivers are often the last to recognize and admit they need care themselves. And yet, if they spiral into depression, or just spend much of the time feeling overwhelmed with too much responsibility, errors in judgment occur and compassion wanes. I’ve found this to be especially prominent in physicians in the middle of their careers whose sparkle seems to have dimmed simply from spending a certain amount of time working at their profession. Many of them seem burnt out just for having cared for sick people for so long. To avoid this, it seems to me, requires a constant reconnecting with the reason for entering the profession in the first place. As hard as it is to be compassionate on any one day, it’s even harder to maintain compassion through decades of stress.

She’s back.
“Researchers like Dr. West are working on finding ways to support the well-being of residents and practicing physicians. ”
I agree with Wonks. I also think, unlike “Dr.” Chen, that normal working hours might help too.

I like my doctor, but the last couple of times I’ve seen him, he has seemed so stressed and overworked. With only 10 minutes of face time, I feel we need to be really focused on why I’m there and make the most of those 10 minutes… but it’s not happening.

I can hardly blame him. I’m in a rural area and we’ve become incredibly short on doctors in the last couple of years. I think he’s doing the best he can, but as the system currently is, it unfortunately is not benefiting my health.

For the physicians out there, what can patients do that would help? (short of not coming in at all cuz that’s not always an option)

“Most of us got into this profession because of passion for medicine, for taking care of people,” Dr. West said. “But somewhere along the way, it gets drummed out. We have to figure out the best ways, the right way, for different individuals to thrive.”
I’ve seen similar sentiments expressed for decades. Isn’t it about time for another Flexner Report? (I refer to the Flexner Study of medical education that occurred about 100 years ago.) It revolutionized the teaching of medicine.
It’s hardly surprising that Flexner’s suggestions of a hundred years ago may need a serious tune-up. All we need is a way to get past the vested interests who like things the way they are. How about throwing some stimulus money at the issue of modernizing medical education — or asking The Gates Foundation to get on this long overdue task?

I strongly believe stress, anxiety, depression and possibly despair are occupational hazards for any busy physician who treats a large number of sick patients.
I remember, as a surgical resident, having to sit for an annual in-service exam that assessed my fund of medical knowledge.
The time has come to also establish an annual psychological assessment for all residents and busy physicians, so that potential coping difficulties can be identified and be expediently managed.

I feel alot of compassion for doctors like Jeff. I’m a physician also, and although didnt have family responsibilities during training, still felt a tremendous amt of stress on a day to day basis to just perform realy well and do a good job. And that’s what physicians are about–they really do care about their patients, and they really want to give excellent care. It is true that the expectations for them (duties, hours, physical stamina, emotional strength) are superhuman. But it is also true that lives are at stake, and we don’t have a different training system in place (and the resources for it) to replace the current crazy schedule. All you can really do as a physician in training is muster the strength and will to keep going and to keep getting better at your job. And, importantly, if you feel impaired, you must admit it and get help so that patients don’t suffer. You’ll get back in the game again, maybe in a different way, but what you don;t want is for an innocent person to suffer from your impairment.

For those of you out there, if you have a good doctor, treat them well. The little smile or thank you you give them may be the only encouragement they get that day for doing a good job, and, in aggregate, this may be the only thing that helps them keep going.

“When you think back 15 or even 20 years ago (I’d change that to 25-30 years ago), the majority of physicians were men, and their wives took care of the kids at home,” Dr. West noted.

Although it’s unknown whether stress levels in medical training are worse today, more and more young physicians have chosen to share family responsibilities.

That choice leaves everyone with less time and energy to devote to patient care.

“If you only have so much gas in the tank, you are going to have to shift responsibilities and deal with less energy for medical practice.”

Times have changed–but our energy levels haven’t.

I see the exhaustion in my son & daughter-in-law with a breast-fed 4 month old who gets them up a couple of times a night–and they still have to get up to go to work!

What Dr. Chen says about doctors holds true for everyone–we can only juggle so many balls, throw one more into the mix–and they all fall down.

It could be a new baby, a sick parent or child, or financial problems.

We all need good sleep to think straight–and repair our bodies.

According to Dr. William Dement, the Stanford sleep researcher:

“If you take any individual and have them get extra sleep, their performance improves. It’s always like here’s my personal best. I’m at my personal – well, it gets better (with the extra sleep). And that’s a big surprise.

As far as I’m concerned, when life’s stresses increase, that’s the time to look at sleep, exercise, “down-time”, & healthy food as medicine.

The root cause of physician stress is now and always has been too many patients. No need to go into why there are too many patients or what the unintended consequence of fewer would be. I need only say that the most direct cure is fewer patients.

Unfortunately this phenomenon is not unique to medicine. My husband and I are both attorneys. He has been practicing for almost 6 years and is an amazing attorney. I have been practicing for 2. I was in law school when we started dating and, due mostly to what I saw of his work life, chose a path different from his. I am not at a big firm, I am not really on a true “partner track” and I don’t make nearly as much money as him. I made this decision because I realized that in order to do all those things I should have gone to law school immediately after undergrad (rather than working for 3 yrs) as I would be 28 by the time I graduated from law school. If I wanted to have kids anytime in the near future, I couldn’t chose the route he chose and have what I deem to be an acceptable family life. What would even be the point of being married if we were both working 70 to 90 hour weeks? For the record, he would support me if I decided to go the partner route (he’s told me this many times and offered his help in finding a job if I want it) but frankly I just don’t want to do it. I’d rather that one of us have time to go to the grocery store and make dinner even if I do have to do it on my way home from work.

Unfortunately, for a lot of young professionals who are married to other young professionals, there is no such thing as work life balance. My husband and I have seen a number of friends struggle with the type of disillusion and distraction Dr. Chen describes in “Jeff.” Our business culture does not allow for family life. In fact, when one friend of ours took 1/2 a day off to take his dogs to the vet, one of the older partners at the firm asked him “why can’t your wife take them?” His wife is a lawyer at an equally high pressure firm. Many superiors still assume that there is a wife at home who can deal with household issues. Frankly, it’s a problem that leads to burnout and disillusionment in a lot of professions and one that the professional (be it medical, law or business) world is loathe to recognize and even more loathe to change.

LOL. Yes. We need to allow doctors – in training and in practice – to have “a life” or some time away from medicine itself. You say that now, in the light of day, but not in the middle of the night when you are worried about x, y, or z. You then become irate that YOUR doctor is not immediately available.

There are stress in every professional occupation. It’s how one deals with it. For doctors, the stress can come in many forms … money, loans, busy schedule, overworked, bad patients, mundaneness of job, how to make more money …

In the new world of health care reform doctors are to be targeted to take continued financial cuts to pay for much of it However office,malpractice, educational expenses will continue to rise unabated. Not to mention the massive administrative burdens about to be imposed by the feds on practitioners. If you think doctor burnout is problem now you ‘aint seen nothing yet.

in response to LK (#15), I totally agree – it’s really HARD to have a family life or any kind of balance with 2 people working 60+ hrs/week.
I’m a well-trained doctor and currently a stay at home mom – I definitely have felt guilty for not using my medical skills to care for patients and am considering some part-time options, but, being married to someone who is working 12+hr days, and having 3 kids, – we did the 2 full-time working parents for awhile, but it was just too stressful. AND I did sometimes feel like my patient care suffered a bit when I was stressed out (I don’t feel I ever caused harm, but perhaps had less patience with staff and did what was necessary -NOT more..feeling like I was a Good enough doctor, but not the Best doctor I could be…).

One of the greatest probelms in health care is the level of responsibility and accountability placed on the physician. The patient see the physician as the end all and be all of their medical care. They don’t see the insurance agencies denying claims, the hospital administrators cutting budgets while the CEOs get paid more, the lack of ancillary staff, the lack of OR time and clinic time. All of that contributes to physician stress but the focus is always on the physician as the problem. There are environmental issues in the healthcare workplace that are largely ignored.

You can treat the physician for depression. You can enforce time off. But the underlying lack of institutional support for a physician to do his or her job is the cause of many of these problems. If I receive one more email from the institution about a lecture on ‘the disruptive physician’ I might become disruptive. The physician is a symptom of the diseased healthcare system that takes medical decision making and care out of the hands of the experts and into the hands of administrators and bureaucrats. When I start seeing the hospital administration take action to change the environment instead of just sending the physician to a psychiatrist I will believe that healthcare institiutions truly take physician burnout seriously.

Speaking as a female internist who completed my training in 1993, I agree 100% with the points made in Dr. Chen’s article. But the public should realize that intense stress DOES NOT end with residency training. Attending physicians actually have more responsibility than residents do, and often have fewer opportunities for taking a “break” for the real world, such as maternity leave….

But my idea of far enough will rub fur the wrong way, it would be to restructure the whole educational/training concept we have now, which relies too much on each individual doctor to “know everything” and “know it instantly” which is already impossible and getting worse. Unfortunately my understanding is that US doctors have not welcomed information technologies nor intermediary “technical support” of lesser degreed people to increase their productivity and reduce their “unproductive face time.” I don’t like the hit and miss approach doctors use to collect patient information and complaints, the endless redundancies, the conflict of processing time and turnover in office visits and sometime premature and sometimes unnecessary confidence building time. To bring costs down, medical services need to be more commoditized and less personal serviced except in moments of major decisions.